Question for those who work in doctor's offices or for an insurance company

My primary care physician has a new policy, the office will not issue any referrals to specialists unless you see the doctor first. Under my insurance, that means I would have to pay a $30.00 copayment just to get my referral and then $50.00 for the specialist. To me this sounds like my primary is charging for referrals which I think is unfair. I have medical issues my primary physician is well aware of and I see specialists several times a year. IF my primary could help me I would of course see him but he himself has told me to see a specialist. I would like to know if anyone else has to see their primary in order to see a specialist (when your primary is aware of the problem and advised you to see a specialist) and if you work for a health insurance company, is the primary allowed to do this in the first place?

* I understand that if I hadn't seen my primary for some time, he would want to see me but I see my primary at least four or five times a year and one of my specialists needs to see me every three months.

I work for an insurance company, but this is the first I have heard of this particular issue, although it doesn't surprise me. Have you spoken with anyone in the office? If you have a history with your doctor, this might not apply to you. I know that my doctor has a sign on her wall where she charges for certain paperwork and things other things because patients have been known to take advantage. This might be the doctor's way for making sure that referrals are really necessary and is charging for the visit and the time.

And you are right. There are folks who haven't been to the doctor in ages and walk in and miraculously expect a referral.

I would certainly expect an HMO to use this type of rule, but haven't heard of doctors doing this. Maybe this is a new trend.

Yes I have experienced this too. Some specialists will not see you unless you have a primary see you first. But it depends on the reason. A dermatologist will see most Pt w/o a referral, so too a fertility specialist, sometimes an ENT or plastic surgeon. But I know that a GI, cardiac, hematologist most often require a referral. Due to the nature of these specialties I can understand the necessity. What kind of specialist were you thinking about, (if I may ask, of course) ?

Check with the specialists, you may not need a referral if you are an established patient. My mother sees a specialist four times a year that normally does not take patients without a referral, but she is an established patient now and no longer requires one.

I have insurance through Aetna and several years ago my plan required referrals, but it was the insurance co and not my primary care physician that had the requirement. Even so, once I had an initial referral to a specific specialist, it only had to be renewed annually and the PCP would do that automatically with only a telephone request from the specialist's office. A few years ago, my insurance dropped the referral requirement altogether - I imagine because they determined it was costing them money rather than saving them money.

If I were you, I'd contact your insurance co to clarify what their actual requirements are. It's not just costing you a $30 copay for an office visit to renew a referral. It's costing your insurance co too.

I need a referral for every visit to the specialist, if I am lucky the referral will cover more than one visit, I don't mind talking about it, I see a rheumatologist for fibromyalgia every three months, and an endocrinologist for an underactive thyroid twice a year I am asking now to see an allergist for a skin rash I have had on and off for over thirty years, I've lost count how many dermatologists and allergists I have seen but the one I have an appointment with next week is suppose to be able to diagnose cases that no one else has been able to. I also have asthma and this allergist is a specialist in treating asthma as well.

I am waiting for my primary to call me, I have been his patient for 17 years and he knows I am not the type of person who likes to doctor hop. I am hoping he will instruct his staff to waive the need for a visit in my case as well as with other patients who have medical issues outside of needing a yearly checkup or a visit for the occassional cold or cough, I hope he tells his staff to just issue the referrals that I need. I have to see my rheumatolgist in December and I really do not want to go through this again.

Of course it's true for you, I certainly didn't mean to question that. Your original post just identified TriCare, that's what I meant.

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Tricare Standard sounds pretty great since you don't need a referral to see a specialist - lucky!! We pay $480.00 a year in premiums. Co-pays are $12.00 for an office visit, and $9.00 for prescriptions. Is that a lot different from the standard plan?

Under my Oxford plan, I pay $30.00 copay for my primary, $50.00 for a specialist and I pay 50% of my prescriptions. I have $1,000 a month deducted from my paycheck and I have a $2,000 deductible as well for in and out of network tests.

Tricare Standard sounds pretty great since you don't need a referral to see a specialist - lucky!! We pay $480.00 a year in premiums. Co-pays are $12.00 for an office visit, and $9.00 for prescriptions. Is that a lot different from the standard plan?

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There's no premium with TriCare Standard. Co-pays are 20% but there is a max of $150 a year for an individual, $300 for a family - after that no co-pay. Prescriptions from a pharmacy are $3, $6, or $9 depending on the tier level of the medicine. If I took a regular maintenance med I'd use their mail in pharmacy and it's cheaper. If I fill a prescription at a base it costs nothing but I don't often do that since the closest base is over an hour away and the only scrips I fill are those I need right away. Eye drops when I had my cataract surgery, antibiotics, etc.

ETA - Of course every time they talk about a military budget TriCare shows up in the crosshairs so things could change.

There's no premium with TriCare Standard. Co-pays are 20% but there is a max of $150 a year for an individual, $300 for a family - after that no co-pay. Prescriptions from a pharmacy are $3, $6, or $9 depending on the tier level of the medicine. If I took a regular maintenance med I'd use their mail in pharmacy and it's cheaper. If I fill a prescription at a base it costs nothing but I don't often do that since the closest base is over an hour away and the only scrips I fill are those I need right away. Eye drops when I had my cataract surgery, antibiotics, etc.

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I live only about 1/2 a mile from the base, but I stopped filling my prescriptions there. The waiting line is always really long, and they were always running out of meds that I needed (they could give me maybe three pills, and then would tell me to come back a in few days for more.) I watch my little two-year old grandson everyday, so that's not a good option for me.

When you say that your co-pay is 20%, how much that usually work out to? I'm kind of interested in this TriCare Standard.

Dang, dang, dang. I wrote out a long reply but I type so slowly FSU threw me off the board and I lost it.

I mostly only see a Primary Care physician a few times a year and pay about $18 or $20 for a doctor visit and blood work - the follow up for the blood work (one week later) is free.

The only exception lately was my cataract surgeon. He doesn't take TriCare so I paid and TriCare sent me a check. it didn't cover his charge but I also have a supplemental policy that paid the difference.

Judiz, I would wait to hear back from your primary. You have an established relationship and just can't imagine why he would charge you $30 per referral. I still think this is for patients who abuse this and expect to get a referral from the doctor without a consultation.

Do your doctors' offices charge a fee to have a prescription called into the pharmacy? I went to another practice as a patient for the first time a few weeks ago and was shocked that they charge $20 per prescription to be called in. It's not exactly rocket science - I probably do 20-30 of them a day as an MA and we don't charge a penny for it. Heck, it's probably the easiest part of my job, takes about thirty seconds or less...

(Although in the long run it probably saves us time and effort given how many patients lose their prescriptions/how bad our doctors' handwritings are. )

Do your doctors' offices charge a fee to have a prescription called into the pharmacy? I went to another practice as a patient for the first time a few weeks ago and was shocked that they charge $20 per prescription to be called in.

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Was there a charge for giving a patient a written prescription? I gotta say I've never heard of such before.

Do your doctors' offices charge a fee to have a prescription called into the pharmacy? I went to another practice as a patient for the first time a few weeks ago and was shocked that they charge $20 per prescription to be called in. It's not exactly rocket science - I probably do 20-30 of them a day as an MA and we don't charge a penny for it. Heck, it's probably the easiest part of my job, takes about thirty seconds or less...

(Although in the long run it probably saves us time and effort given how many patients lose their prescriptions/how bad our doctors' handwritings are. )

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No fee for prescription renewals, just a warning that it could take up to four days for it to get done.

I would like to know if anyone else has to see their primary in order to see a specialist (when your primary is aware of the problem and advised you to see a specialist) and if you work for a health insurance company, is the primary allowed to do this in the first place?

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What does your insurance policy stipulate?

My own health insurance (EPO) says that I don't have to get a referral to see a specialist. When I had my stroke several years ago and called for a follow-up visit to the neurologist who treated me when I wound up in the ER, I almost got into an argument over the phone with his secretary over this. I got the appointment, and made a point of bringing in a copy of my insurance policy to prove "no referral necessary" if the subject came up again.

I work at an insurance company and have been in the industry since the early 80s.

The requirement for a referral waxes and wanes. Right now, insurers are pressuring primary care physicians to set up their practices so that they are ready to become "medical homes" so that they can receive higher reimbursement under Federal Health Care Reform. Also, many insurers and specialists have issues with self-referrals as there is a segment of the population that insists on seeing a neurologist for every headache, and an orthopedist for every joint ache.

I would recommend calling the insurance company and asking if the primary care copay can be waived if the sole purpose of the visit is to obtain a referral. Then, ask what their policy is about the 2nd and subsequent visit to the same specialist. Do they keep the referral open for the duration of your problem, or for a specific length of time?

Also, to avoid having to pay for a second visit, anytime your doctor recommends a specialist, DO NOT LEAVE THE OFFICE, until the doctor has entered the referral in the system!!! Having the right paperwork with the right dates is key.

Getting familiar with your policy is the best way to get what you need when you need it.

Was there a charge for giving a patient a written prescription? I gotta say I've never heard of such before.

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No, just called into the pharmacy. I know this because the NP I saw sat down in front of me and immediately started writing out prescriptions. When I told her that it was okay, I still had refills from my primary provider, she shook them in my face and said "Well, take them anyway!!" (I didn't get billed for that, and I'm not going back there.)

It's getting to be a pain to find a decent ob-gyn in this area that takes my insurance... another one I looked at has horrible ratings everywhere online. Why? Because apparently she reuses the disposable speculums. As in, rinses them and chucks them right back into the drawer, right in front of the patient. If it was just one person who claimed this amongst other good reviews I'd be inclined to think they were making it up, but when multiple people are saying it,

It's getting to be a pain to find a decent ob-gyn in this area that takes my insurance... another one I looked at has horrible ratings everywhere online. Why? Because apparently she reuses the disposable speculums. As in, rinses them and chucks them right back into the drawer, right in front of the patient. If it was just one person who claimed this amongst other good reviews I'd be inclined to think they were making it up, but when multiple people are saying it,

In my case it wasn't a frivolous visit. The neurologist told me he wanted me in for a follow-up when I was still in the ER.

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I think your situation was a bit different than the "segment" I describe. You were diagnosed in the ER.

The people that my ins co has trouble with are the people who never see their PCP and go directly to a specialist for any concern. The first thing a specialist will want is records from the PCP... what was the complaint, what tests have already been done, what is the follow up plan? Going directly to the specialist can actually slow down care in some cases.

Our insurance recently changed so that we need first time referrals for all specialties except dermatology, ophthalmology and audiology. If someone sees a skin change or has a change in vision or hearing, the PCP is unlikely to offer any advice other than to see someone else, so that policy saves time and money. For everything else, the PCP sets up the referrals and recommends a duration. For example, the Allergy referrals are usually for one season or one year, depending on the allergy. So far, the system works pretty well.

My insurance doesn't require a referral, although I recently went through them to get an appt with a dermatologist since the PCP's office could get me an appt with a doctor in their practice faster than I could get an appt if I just called directly.

My doctor belongs to a medical group. If I need to see a specialist in that group, I need a referral from her even though my insurance doesn't require it. However, if I decide to see a specialist outside the medical group, I just call them and make an appointment. So far, I haven't self-referred myself to any specialist who required a referral from my PCP but the ones I see outside my medical group are things like my Sports Medicine Doctor.